Introduction to the methodology

a. Why focus on cultural differences?

Does culture really have an impact on the daily work of health professionals? Or are we just misusing references to culture and identity to hide real sources of problems such as differences in power or economic resources, even systemic discrimination? The approaches focusing on diversity have been struggling from the very beginning between emphasising the impact of cultural differences (thus running the risk of reifying, essentialising culture and reinforcing differences) or to the contrary deconstructing culture, focusing on all personal, situational, economic factors underlying people’s behaviour (running the risk of denying the relevance of culture). Suspending the theoretical debate and changing register to focus on the level of practice, the method of critical incidents developed by French social psychologist Margalit Cohen-Emerique offers a passage between these two risks. It proposes an ingenious strategy to uncover the set of cultural norms, values, behaviours that people bring into an encounter with others, and which filter the way they interpret and respond to others. Through lifting the often negative emotional haze surrounding intercultural misunderstanding, it helps to become aware of the illusion of our own cultural neutrality, and invites us to explore the cultural reference frames in a more objective way, and opening up a margin for negotiation where prejudice has a lesser role to play.

b. How to focus on cultural differences?

Adopt the wide anthropological understanding of “culture” to embrace a great variety of facets of human action, thinking and identification. Cultural groups are often connected to nationality or ethnicity, but they can take many forms: social class, gender, age, sexual orientation, subcultures related to sports, music, but also professional cultures.

Be aware that no culture is homogeneous and static, that they are in permanent change. There has always been exchange between different cultures, just think of the traditional dishes and see how many ingredients come from other countries or continents. Also, try to juxtapose images of your city from today and two hundred years ago. You will see radical changes that affect also the subjective experience and value system of people creating utterly different worlds in the same place.

Acknowledge that each person bears a plurality of cultures and that each individual acquires and integrates these cultures through their own particular life path.

Remember that culture is not the only factor determining our behaviour: but only one that interacts with situational factors (e.g. crowd, fatigue) and personality (eg: personal predisposition for kindness or aggression).

Adopting these will help to address questions of diversity in a positive way, considering intercultural situations as learning opportunities. Finally, and maybe most importantly we have to remember, that “difference” is not an inherent characteristic of another person or another group. In order to speak about differences, we need two sides (at least) whose relative differences we can detect. Accordingly, we needed a method that helps us uncover differences existing between two or several patterns. This is why we turned to the methodology proposed by French social psychologist Margalit Cohen-Emerique which is based on the occurrence of “culture shocks”.

c. What is a culture shock?

The concept of “culture shock” has been used in a variety of definitions and perspectives, so let’s start clearing up how we understand it.

Culture shock is an interaction with a person or object from a different culture, set in a specific space and time, which provokes negative or positive cognitive and affective reactions, a sensation of loss of reference points, a negative representation of oneself and feeling of lack of approval that can give rise to uneasiness and anger.

(Cohen-Emerique 2015:65)

Let’s pick up some key elements of this definition:

Culture shock is about people’s real experiences, not fantasies, not theories about what could be a source of clash or tension, but situations that have actually happened where we suspect that cultural differences may have played a role.

Emotions point to culture shock: emotions (positive or negative) act as indicators, pointing to the direction where something important has happened, maybe because it threatens a value or norm we hold dear, or maybe because it is against our expectations. In any case some emotion accompanies each experience of culture shock, this is how we can detect that we have just experienced it. Sometimes it is a diffuse sense of being lost, but it can be a very powerful anger, disgust, or fascination…

Culture shock can be positive or negative: not all culture shock experiences are negative, some people experience positive culture shock, for instance when city-dwellers encounter the Yanomami living in the rainforest, perceiving them as living in ‘total harmony with nature’. Positive or negative, the experience tends to motivate us to create a simplistic image of the other instead of trying to perceive them in all their complexity (yes, the Yanomami live in more harmony with nature, but they also have their daily fights).

Culture shock can inspire judgments: In some culture shock situations we witness a behaviour that breaks with a cherished norm (e.g.: someone ending a meal with a loud tasty burp) the interpretation is almost automatic: how rude, how impolite. In other situations we commit cultural mistakes, breaking norms and we are reminded of our mistakes, depending on our character and the severity of the situation, we may feel ashamed and guilty (“I should have known”). Either way it is very easy to close a situation by a negative judgment on the other or ourselves. One of the reasons is that because these situations tend to be unpleasant we try to close them as soon as possible. Judgment is a good way to do so: we don’t need to investigate, try to understand the other, because they are fundamentally rude, sexist, authoritarian etc.

d. How to use culture shock as a research tool?

If culture shocks can reinforce stereotypes, all such incidents also have the potential to become a powerful source of learning if we don’t obey our need to close and quickly forget the situation but ponder on what may be behind it…

A French teacher working in Korea shared with us the following story:

I was a French teacher at a military academy in South Korea. It was winter and I was giving my lesson as usual, but I couldn’t help noticing that most of the cadets had colds and quite a few had runny noses. None of them attempted to blow their noses and just continued to sniffle throughout my lesson. I was a bit annoyed by this as it made it difficult to concentrate on my lesson. Finally, I took out a packet of tissues and attempted to distribute tissues to the students with runny noses so that they could blow their noses. I was quite surprised when they all refused the tissues because they clearly needed them. After they refused the tissue, I continued my lesson as usual, but I remained confused by their reaction.

After she finished the lesson, our teacher was brave enough to investigate what may have happened here, and she ended up discovering that in Korea it is considered as rude to blow our noses as in Europe to make the sound of sniffing back the mucus. Both these behaviours have their roots and explanations, which explain the rationality of the behaviour. The young boys don’t seem so distasteful and impolite anymore, as they are obeying an important cultural rule. All in all, in culture shock we learn about the other, but also about our own culture.

What’s more, exploring what are the most frequent themes of culture shock – or critical incident helps us to unveil the sensitive zones, which are cultural domains of particular importance, susceptible to become a source of tension in intercultural contact.

e. Where do the incidents come from?

This is indeed what we did for the Healthy Diversity project, interviewing and asking health care professionals, auxiliaries, administrative staff, patients and their relatives in Austria, UK, France, Italy, Denmark and Hungary. The incidents were either collected through workshops or through individual interviews or the combination of the two. A total of 70 critical incidents have been collected between March and June 2016. We have analysed 50 of these incidents together alongside the narrators. In the following manual you can read the incidents and how they were interpreted.

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